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HomeMy WebLinkAboutBLDP-22-002686 (2) • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 11/9/21 PERMIT# BLDP-22-002686 JOBSITE ADDRESS 8 ORCHID LN OWNER'S NAME MCCARTHY JEFFREY T P OWNER ADDRESS MCCARTHY LAURA C 8 ORCHID LANE WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOORS-' RAM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Stephen Winslow LICENSE 1E298 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY SYARMOUTH STATE MA J ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.cow ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El FEES$ PERMIT# PLAN REVIEW NOTES • 7 .r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK T- _ , CITY [YARMOUTH (WEST) MA DATE '1110212021___A PERMIT # 2 — '2 (v $IC AP JOBSITE ADDRESS L8 ORCHID LANE, W YARMOUTH, MA 02673 J OWNER'S NAME JEFFERY MCCARTHY P _ ___ OWNER ADDRESS SAME TEL 7743536853 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL L j EDUCATIONAL —1 RESIDENTIAL PRINT CLEARLY NEW: RENOVATION REPLACEMENT 1 � PLANS SUBMITTED: YES ; NOIJ '' FIXTURES -1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I. ,, w 0 � 1 CROSS CONNECTION DEVICE 1 . DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILJSAND SYSTEM _IL....., i 1[ _n. . iii. DEDICATED GREASE SYSTEM1 61111110 I f DEDICATED GRAY WATER SYSTEM _ II I _ DEDICATED WATER RECYCLE SYSTEM OM 4-- ri DISHWASHER �� � _ _ �_ DRINKING FOUNTAIN I __.swim,I FOOD DISPOSER , . .. ' FLOOR /AREA DRAIN _ = E.no l i, INTERCEPTOR (INTERIOR) — t,..... 17 ME ._ : .,. ,., � - KITCHEN SINK ...._. ii L._ ..:..... ._ LAVATORY 111111111111.I I _ ma _.: ! �e,-m..-. , _m, _ I. ROOF DRAIN I �.��n�.� ,. __ _,__ .. _....�.� .- --�_ __m�. .�..� ..: 3 SHOWER STALL F . ..' 11 _. _,_..' _- ._1f I _ SERVICE 1 MOP SINK I _.__ T L L1 1_._�_ , .�__ ,. ,�,,._ TOILET _ . � �'.. - ��.I . .. ...� � _ ) ii- _ .... URINAL ' .� L � � _ M WASHING MACHINE CONNECTION I .. - _ I1. _ = .,.._ r , WATER HEATER ALL TYPES 1 i * x 1 ;; _ 1 . 1 WATER PIPING II ._ .� OTHER s , 1 r ' DS :)_ 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ;,_ NO ri IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY BOND , OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the O Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ri AGENT `` s SIGNATURE OF OWNER OR AGENT ` 1 ) I hereby certify that all of the details and information I have submitted or entered regarding this application are true r to to the b t of my knowledge —� and that all plumbing work and installations performed under the permit issued for this application will be in co Ha with II ertine proxisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE # [122981 SIGNATURE P'M JP CORPORATION , # 3281C IPARTNERSHIP #[ COMPANY NAME LE.F. WINSLOW PLUMBING & HEATING ADDRESS = 8 REARDON CIRCLE CITY i SOUTH YARMOUTH STATE ' MA ZIP 02664 TEL 508-394-7778 FAX 508-394-82561 CELL rN/A ' EMAIL [iC1]ONS©EFWINSLOW COM ...._ uw.0 «,..xwn«.........„....„..n .... .........xmw......m ..mw.n..m...,wxmmv .mmavwmmv. f The Commonwealth of Massachusetts J Department of Industrial Accidents Office of Investigations (7 w\ Lafayette City Center : 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC. Address: 8 REARDON CIRCLE City/State/Zip: SOUTH YARMOUTH, MA 02664 Phone #: 508-394-7778 Are you an employer? Check the appropriate box: Business Type(required): 1.❑■ I am a employer with 90 employees (full and/ 5. ❑ Retail or part-time).* 6. U Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date: 01/01/2022 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' the ins and penalties of perjury that the information provided above is true and correct. Signature: T2-// -^- '--- Date: 01/02/2021 Phone#: 508-394-7778 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia